342700492-6-25-2021-27-AS-VBRN-C4BRKJ-20210625130536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700492
Report Date: 06/25/2021
Date Signed: 06/25/2021 01:05:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LOVE AND SERENITY III		FACILITY NUMBER:	342700492
ADMINISTRATOR:	JULIE NONU		FACILITY TYPE:	740
ADDRESS:	573 SHAW RIVER WAY		TELEPHONE:	(916) 469-9145
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 0	DATE:	06/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Mike Her		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Prior to arrival at facility Licensing Program Analyst (LPA) Victoria Brown asked the Licensee the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? Fever or chills, Cough, Shortness of breath/difficulty breathing, Fatigue, Muscle or body aches, Headaches, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, and Diarrhea. Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? LPA received a "No" answer to all of the above questions. Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 6/25/21 at 12:10PM. Administrator Certificate expires 4/11/22. LPA met with Mike Her, Administrator and stated the purpose of todays visit. The facility is licensed for a capacity of 6 residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. See 809C for continuation...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY III	FACILITY NUMBER: 342700492
	VISIT DATE: 06/25/2021

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809 continued...

LPA observed adequate supply of 2-day perishables and 7-day non-perishables. There are no residents at this time.

The temperature inside the facility was observed to be at 68*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

Facility has a Hospice Waiver for 2 and there is 0 residents utilizing the services at this time.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Liability Insurance
Personnel Report (LIC500)
Administrator Certificate-Updated
License Fees due-Pin number given as an option to pay during this visit

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

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